How to Prevent Clostridioides Difficile Infection in Patients With IBD and Achieve Optimal Outcomes

Inflammatory bowel diseases (IBD) are common among adults in the United States. Of those with IBD, it is estimated that 6% of IBD patients also present to hospitals with Clostridioides difficile infection.

With us today is Christina Ha, MD, associate professor of medicine at Cedars‑Sinai Medical Center, who will answer our burning questions on the prevention of C difficile infection, as well as how to achieve better patient outcomes for those with IBD who develop the infection.

Preventing C diff in any patient is key, but why is it especially vital for a patient with IBD?

CH: That’s a great question, and it’s really important for inflammatory bowel disease patients because C difficile has a greater prevalence in the IBD patients than the non‑IBD patients. When an IBD patient—particularly those with inflammatory colitis, whether it be Crohn colitis or ulcerative colitis—get the C difficile infection, it’s associated with greater likelihoods of hospitalizations, disease flares, colectomies, failures of not only C difficile infection‑related therapy, but also failures of inflammatory bowel disease‑related therapy. So there’s a lot of downstream effects for having a C difficile infection, so the idea is the earlier we can identify it, hopefully, the earlier we can intervene in a successful manner.

What are some of the best practices for prevention of C difficile among patients with IBD and the challenges to achieving them?

CH: The main principles are still the same principles as for the general population. We want to avoid excessive use or unnecessary use of antibiotics. Oftentimes across the board, regardless of whether you have IBD or not, we prescribe or recommend antibiotics for many conditions where they’re not necessary.

We oftentimes recommend if you have a cold‑like symptom, don’t automatically jump to the antibiotics because, by far, most of those are viral-related etiologies. But if you do need antibiotics, try to stick to the shortest course possible, and always just monitor your symptoms carefully.

We do know of the IBD-related medications, one that’s probably the most associated with C difficile infection risk is steroids. Across the board, we don’t like to keep anybody with Crohn disease or ulcerative colitis on steroids for too long, not only because of the downstream effects of chronic steroid exposure, but because it does increase the risk for C difficile.

And not just for C difficile, but overall, it’s very important to utilize appropriate sanitation practices. And that certainly includes washing your hands. The difference with C difficile compared to some of the other bacterial viruses and fungi that are out there is that alcohol foams or the hand sanitizers are really ineffective at killing the spores. So the best practices are to wash your hands carefully, at least 20 seconds in warm water with soap, and to dry them carefully. Those are the same recommendations that we would make for our IBD patients.

However, if they notice symptoms of increased cramping, diarrhea, bleeding—which could mimic a Crohn disease or ulcerative colitis flare—[I] also remind all my colleagues to check for C difficile. Even if they’ve had a negative C difficile in the past, it can crop up at any time, even without exposure to steroids or antibiotics.

You just mentioned some of the ways to prevent C difficile. However, let’s say a patient with IBD does have C difficile. Your focus at this point is obviously not on prevention, but on achieving the best outcome. What are some of the best practices and, again, their challenges to achieving good outcome?

CH: Well, the first is to make sure that it’s truly a C difficile infection and not just colonization, because a lot of our patients may be colonized with C difficile. And what I mean by that is that most common commercial testing that’s done to check for the presence of C difficile is the C difficile qualitative PCR test. And that’s oftentimes positive, even if you may not truly have the infection, so you do need a second confirmatory test. That’s usually the enzyme immunosorbent assay, or the EIA, for toxin A and B. If you have both of those, the PCR and the EIA for toxin positive, then it’s truly an infection. If the PCR is positive and the EIA is negative and the patient’s having symptoms, it’s more likely due to their underlying inflammatory bowel disease.

That’s the first step is to make sure we’re treating the right thing. If they do have C difficile infection, automatically, by simply just having a diagnosis of inflammatory colitis, we should be treating them as though they have severe disease. According to the Infectious Diseases Society of America and our recent ACG guidelines, the first‑line treatment is vancomycin.

There’s no role for doses higher than 125 milligrams, 4 times daily, so vancomycin tends to be the first‑line treatment. If somebody cannot tolerate vancomycin, another option is fidaxomicin at 200 milligrams, twice daily, for 10 days. But our first‑line treatment for C difficile is first to confirm that it truly is the infection. The second is to use vancomycin as first‑line, or potentially fidaxomicin if there’s a contraindication. The third is to also make sure that you don’t forget to treat the underlying inflammatory bowel disease, as C difficile infection can make the underlying inflammatory colitis worse.

For more on this topic, listen to the full interview here: https://www.hmpgloballearningnetwork.com/site/gastro/podcast/gastroenterology/inflammatory-bowel-disease/christina-y-ha-md-managing-c-difficile